| NPI | 1457601650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3010545) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH COA13811NP) |
| Enumeration Date | 2012-09-14 |
| Last Update Date | 2021-05-28 |